© 2004 by European Society of Cardiology
Copyright © 2004, The European Society of Cardiology
Coronary artery aneurysms mimicking cardiac tumor
aDepartment of Cardiology, Rikshospitalet University Hospital, N-0027 Oslo, Norway
bDepartment of Cardiothoracic Surgery, Rikshospitalet University Hospital, N-0027 Oslo, Norway
cDepartment of Radiology, Rikshospitalet University Hospital, N-0027 Oslo, Norway.
Received 4 December 2003; received in revised form 24 February 2004; accepted after revision 24 February 2004.
ole-gunnar.anfinsen{at}rikshospitalet.no
* Corresponding author. Tel.: +47-23-07-00-00; fax: +47-23-07-39-17.
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Abstract |
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 Top Abstract 1 Introduction2 Case 13 Case 24 Case 35 Discussion6 ConclusionReferences |
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Aims: To discuss the diagnosis of giant coronary aneurysms.
Methods and results: We describe three patients in whom initial echocardiographic findings suggested cardiac tumors in the right atrium. Additional examination proved the tumor-like structures to be giant atherosclerotic coronary aneurysms of either the right coronary artery or its saphenous vein coronary bypass graft.
Conclusion: Giant coronary aneurysms are an important differential diagnosis for cardiac tumors.
Keywords: Coronary aneurysms; Cardiac tumors; Echocardiography; Cardiac imaging; Coronary atherosclerosis
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1 Introduction |
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TopAbstract1 Introduction2 Case 13 Case 24 Case 35 Discussion6 ConclusionReferences |
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A coronary artery aneurysm has been defined as a coronary dilatation that exceeds the diameter of the normal adjacent segments or the patient's largest coronary vessel by 50%.1 The diagnosis is usually made by coronary angiography. Among patients undergoing cardiac catheterization, reported incidence varies between 0.3 and 4.9%.1 Far less frequently, giant coronary aneurysms occur that are visible by echocardiography. We describe three patients referred to our hospital with an initial diagnosis of cardiac tumor.
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2 Case 1 |
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TopAbstract1 Introduction2 Case 13 Case 24 Case 35 Discussion6 ConclusionReferences |
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A 73 year old man with a history of cerebrovascular insult and an inferior wall myocardial infarction was hospitalised due to progressing heart failure over the last two months. Transthoracic echocardiography showed a cystic tumor 5 x 6 cm close to the posterolateral wall of the right atrium, nearly filling the whole cavity of the atrium (Fig. 1). The left ventricle was dilated with global hypokinesia, ejection fraction 15%, and cardiac output 2.9 l. Coronary angiography was not performed at arrival due to an elevated INR. Magnetic resonance imaging (MRI) of the heart was scheduled, but before that, the patient died from ventricular tachycardia and cardiogenic shock. The post-mortem examination revealed that the tumor was a giant aneurysm of the right coronary artery, 5 cm in diameter and filled with thrombotic material. The right coronary artery (RCA) was occluded 10 mm distal to the ostium. There was a fresh thrombus in the circumflex branch of the left coronary artery (LCX).
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3 Case 2 |
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TopAbstract1 Introduction2 Case 13 Case 24 Case 35 Discussion6 ConclusionReferences |
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A 60 year old lady was admitted to our hospital with a tentative diagnosis of myxoma. She had suffered from asthenia and periodical dyspnoea, and also complained of abdominal pain during the previous year. Sedimentation rate was repeatedly elevated around 50 mm per hour. Transthoracic echocardiography showed a tumor 3 x 3 cm apparently within the free wall of the right atrium. There was no impairment of intraatrial flow, and the heart was otherwise normal. Transesophageal echocardiography (Fig. 2) confirmed a spherical tumor within the right atrial wall immediately proximal to the tricuspid valve. There was no visible flow within the tumor. MRI of the heart showed the tumor consisting of two lobes and surrounded by adipose tissue. Computed tomography (CT) of the thorax and abdomen showed a slightly enlarged lymph node between the esophagus and descending aorta, and otherwise no additional pathology. Coronary angiography showed both the left and the right coronary arteries to be extremely ectatic, but without significant stenoses. The patient was surgically explored because of uncertainty whether the tumor was of neoplastic or aneurysmatic origin. Pre-operatively, the tumor was found to be a giant aneurysmatic RCA. The aneurysm was extirpated, and the RCA reconstructed by an interposed saphenous vein graft. Histologic examination confirmed a coronary artery aneurysm with atherosclerosis and thrombosis, but without signs of neoplasia. The patient has been observed uneventfully for six months post-operatively.
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4 Case 3 |
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A 55 year old man had a history of a myocardial infarction 15 years ago, and bypass surgery in 1991 (left internal mammary artery (LIMA) to the left anterior descending artery (LAD) and two venous grafts to the RCA and LCX). He was referred to the Department of Neurology due to dizziness and general weakness. He reported increasing anginal symptoms over the last year. Transthoracic echocardiography showed a spherical tumor 4.5x5 cm (Fig. 3a) extending into the right atrium and right ventricle, but without obstructing the tricuspid orifice. There was regional hypokinesia of the inferior wall of the left ventricle, with global ejection fraction 40%. Coronary angiography showed occlusion of all three main native coronary arteries, but a well-functioning LIMA-graft. The venous graft to LCX was occluded. The graft to RCA was open, but very dilated and apparently served the tumor (Fig. 3b). At MRI, the tumor of 8.5x4.0x4.5 cm was seen in close relation to the RCA, partly surrounding the artery. By contrast administration, the central part of the tumor was filled simultaneously with the RCA (Fig. 3c), thus suggesting a large, partly thrombotic aneurysm of the RCA or its venous graft. We have chosen not to operate on this patient due to the risk of damaging his well-functioning LIMA-graft.
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5 Discussion |
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TopAbstract1 Introduction2 Case 13 Case 24 Case 35 Discussion6 ConclusionReferences |
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Coronary artery aneurysms are more common than primary cardiac tumors,1,2 and will probably be diagnosed more frequently as a consequence of the widespread use of coronary arteriography.3–6 However, large aneurysms, in particular when partially or completely filled with mural thrombus, may create diagnostic problems. Atherosclerotic aneurysms are most frequent, but aneurysms may also be congenital, mycotic or part of a systemic inflammatory disease like polyarteritis nodosa or the mucocutaneous lymph node syndrome of Kawasaki. Differential diagnoses include pseudoaneurysms of the anastomotic areas, and graft aneurysms after coronary artery bypass surgery,6–8 as well as pericardial cysts. Pericardial cysts are congenital, and typically are located in the cardiophrenic angles. Primary cardiac tumors have an incidence of 0.002–0.3% in autopsy series,2 of which histologically benign myxomas constitute the majority. Metastatic tumors to the heart are more frequent, particularly among patients with carcinomas of the lung and breast, lymphoma and malignant melanoma.
Coronary aneurysms appear because the atherosclerotic process affects both the endothelium forming luminal stenoses or occlusions, and the media and adventitial parts of the vessel wall resulting in arterial remodelling and dilatation.9 We expect giant coronary aneurysms to be diagnosed more frequently as patients receiving modern medical therapy live longer with their coronary heart disease after their initial symptoms.
Two of our patients developed giant aneurysms in the right coronary artery, while the third one was found in the graft to the RCA. This is in accordance with previous reports, which showed the RCA to be affected in 68% of patients, LAD in 60% and LCX in 50% (frequently more than one aneurysmatic area per patient).1 As shown in Fig. 3, coronary angiography may underestimate the dimension of aneurysms that are partly filled with thrombotic material. Angiography may even be false negative if the native vessel occludes.
The giant coronary aneurysms of our three cases probably have developed over a long period of time without eliciting specific symptoms. One may speculate whether partial compression of the right ventricle could be a reason for the dizziness in case 3, but otherwise these aneurysms were incidental findings in patients with moderate anginal symptoms. On the other hand, coronary aneurysms may predispose to thrombosis, embolism or rupture with sudden death, although the absolute risk is not known. In other cases, coronary artery aneurysms may break through to the right heart or coronary sinus, creating left- to right-shunts.10,11 Previous studies based on the angiographic diagnosis have, however, shown similar prognosis whether patients have coronary aneurysms or not.1 Thus, prognosis seems to be determined by the coronary atherosclerosis per se, and not by the presence of aneurysms. The indication for surgery will be the presence of ischemic symptoms, or to close hemodynamically significant shunts, and only exceptionally for verification of diagnosis. Surgical repair by exclusion of the aneurysm and revascularisation of the affected myocardium may be performed according to anatomy. There are some reports of percutaneous transcatheter treatments of aneurysmatic coronary arteries,12,13 of which the use of polytetrafluoroethylene-covered stents may allow exclusion of the aneurysm with maintenance of blood flow in the artery.12
Since thrombosis is commonly present, antiplatelet and anticoagulation therapy is often prescribed.14 However, it is unclear whether this treatment influences the prognosis among patients with coronary artery aneurysms any more than in patients with coronary atherosclerosis in general.
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6 Conclusion |
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TopAbstract1 Introduction2 Case 13 Case 24 Case 35 Discussion6 ConclusionReferences |
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Giant coronary atherosclerotic aneurysms may echocardiographically mimic cardiac tumors. Coronary angiography and magnetic resonance imaging usually add valuable diagnostic information, but sometimes the diagnosis is not made until open-heart surgery. Treatment should be guided by the patients' symptoms from coronary atherosclerosis, while the presence of coronary aneurysms per se apparently has a limited influence on the prognosis.
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